VII. Key Issues: Regulation & Reform >> C. Health Reform >> Affordable Care Act (ACA) >> ACA and the Health Sector >> ACA and Physicians (last updated 9.23.16)
Lead Editor – Dana Beezley-Smith, Ph.D.
Also see Physician Shortage
- 1 Physicians and Health Insurance Exchange Plans
- 2 Changes in Physician Practice Models
- 3 Increased Regulatory and Administrative Burdens
- 4 Physician Stress and Burnout
- 5 Impact on Physician Income
- 6 Research and Analysis
- 7 Retail Medicine
Increased Regulatory and Administrative Burdens
- See Health Information Technology (HIT) for requirements accelerated by the ACA. Includes information on EHRs and Meaningful Use.
Six Months of Obamacare and I’m Headed Towards Bankruptcy: One Doctor’s Insights. “I want to share with you what has been happening around me as a private practice physician since Obamacare was enforced.
- The number of my Medicaid patients has risen by 12% and the number of private insurance patients has declined by 22%. I must see three to four Medicaid patients to earn the same amount as one of my patients with private insurance.
- Referring doctor supply is shrinking rapidly. 20% of my referring doctors have left private practice completely! This was the most astonishing and disappointing discovery for me. Several doctors who used to refer me 10 patients a week, on average, have already quit medicine completely. One of my greatest referral sources is now earning 3X as much working as an HMO administrator, and many of my most loyal referring docs have moved to work for hospitals, large medical groups, or HMOs like Kaiser. Referrals of new patients have consequently plummeted dramatically.
- Doctors retiring much earlier than before. 5% of my referring doctors retired from medicine in the last six months alone. They were young by retirement standards (in their 50s-early 60s)
- Concierge practices on the rise. 10% of my referring doctors have decided not to take insurance at all or have decided to practice “concierge medicine” and charge yearly retainers ranging from $500/patient to $20,000/patient. They are seeing fewer patients now and that means fewer surgical referrals. As a surgeon, the concierge model is not a viable option because we don’t usually treat chronic patients.
- Emergency Rooms far busier with more (not fewer) uninsured patients. My emergency room on-call work hours at my local hospital have quadrupled and the number of uninsured patients that I have seen on-call has quadrupled as well…
Doctors: I sincerely hope that you are not experiencing any of these difficulties and that my personal situation is entirely unique. I hope that I am still a dreamer and that this is just one very long bad dream. Sincerely, Once Hopeful Surgeon. (DoctorCPR.com, 6.20.14)
- The Medicus Firm Physician Survey: Health Reform May Lead to Significant Reduction in Physician Workforce (January 2010) “It’s probably not likely that nearly half of the nation’s physicians will suddenly quit practicing at once. However, even if a much smaller percentage such as 10, 15, or 20 percent are pushed out of practice over several years at a time when the field needs to ‘expand’ by over 20 percent, this would be severely detrimental to the quality of the health care system. Based on the survey results, health reform could, over time, prove to be counterproductive, in that it could decrease patients’ access to medical care while the objective is to improve access. Furthermore, even if physicians are unable to act upon a desire to quit medicine, there could be an impact in quality of care due to a lack of morale in physicians who do continue to treat patients despite feeling significantly stressed.”
- Will a “Silent Exodus” from Medicine Worsen Doctor Shortage? “‘This is a silent exodus,’ said Mark Smith, president of Merritt Hawkins. ‘Physicians are feeling extremely overtaxed, overrun and overburdened.’ Only half of doctors will continue their current practice during the next three years, the survey said. Many plan to cut back on hours, retire, see fewer patients, seek hospital employment, work part time, transition to a concierge model or seek a nonclinical job in health care. Sixty percent would retire today if they could, compared with 45% in 2008.” (AMED News, 10.8.12)
- Physicians Worry over Payments, Red Tape. “Most primary care physicians love their work, but they are clearly frustrated about their income and the increasing compliance challenges associated with payers and government initiatives, according to results from the 85th annual Medical Economics 2013 Exclusive Continuing Study, which collected responses from physicians about their professional life…Nearly 45% of internists responding to this survey said that if they could go back in time, they would change either their specialty or their career. The same sentiment was expressed by 43% of the family physicians who responded.” The most frequently cited professional concerns were fees and reimbursement (68%), burden of paperwork (56%), and healthcare reform (54%). (Medical Economics, 11.25.13)
- Nearly Half of Physicians Believe the ACA will Impact Their Career Timelines, Survey Finds. “A recent survey shows that nearly half of physicians believe the ACA will somehow impact their career timelines by either leaving practice earlier than they planned or in some cases, leaving it as soon as possible…When asked how the implementation of the ACA will affect their career time lines, 30% of respondents said they will leave the practice of medicine as soon as it is feasible for them to do so, and 19% said they will practice medicine for a shorter period of time than they originally anticipated.” (Medical Economics, 11.29.13)
- Physician Retirement Accounts for Higher Share of Turnover. “Demographic-driven retirement is predictable. What’s unpredictable is the rate of early retirement among physicians who are unhappy about government regulation, declining reimbursement, the bumpy transition to electronic health records, and the loss of professional autonomy. A survey released last year by the Deloitte Center for Health Solutions reported that 60% of physicians would retire today if they had the financial means to do so. AMGA’s O’Connor said this sense of disillusionment probably contributes to the jump in physician turnover caused by retirement. ‘There is a growing level of frustration,’ said O’Connor. Cornett agrees. ‘All the changes in healthcare have been increasing the pressure for physicians to retire early,’ said Cornett.” (Medscape Medical News, 8.26.14)
- Physicians Foundation Data: 44% of Physicians Surveyed Plan to Reduce the Number of Patients They See to Alleviate the Demands of the Profession. “As the nation adjusts to Medicaid expansion, a graying demographic, and extended health insurance coverage for millions of Americans through the public exchanges, 81% of physicians say they’re either overextended or at full capacity, The Physicians Foundation survey shows. While 19% of the 20,088 physicians surveyed said they would take on more patients, 44% said they would reduce the number of patients they see, either by reducing their workload, working part-time, retiring, or transitioning to non-clinical jobs… ‘But many say that between entering data and calling for prescriptions permission and trying to avoid Medicare penalties, when is there time to see my patients?’ The survey also found that:
- 39% of physicians said that they will accelerate retirement plans due to changes in the healthcare system
- 26% of physicians now participate in an Accountable Care Organization, but only 13% believe ACOs will enhance quality and decrease costs
- 50% said implementation of ICD-10 will cause severe administrative problems in their practices
- Physicians spend 20% of their time on non-clinical paperwork
- On average, physicians said 49% of their patients are in Medicare or Medicaid
- 38% either do not see Medicaid patients or limit the number of Medicaid Patients they see
- Physicians work an average of 53 hours per week and see approximately 20 patients per day.” (Health Leaders Media. 10.2.14)
- More Doctors To Retire As MACRA And Value-Based Pay Hit. “The nation’s doctors, facing a tsunami of changes in how they are paid, plan to retire in droves as value-based pay replaces fee-for-service medicine and they are forced to implement more new regulations, according to a new report. The biennial survey from the Physicians Foundation shows 46% of physicians plan to ‘accelerate’ their retirements, cut back on patients or seek ‘non-clinical roles,’ according to the group’s survey, which is conducted by physician staffing and recruitment firm MerrittHawkins. More than 17,000 physicians are polled, Merritt said. Not all of these doctors will leave medicine right away, with 14.4 % of physicians saying they will retire in the next one to three years compared to 9.4% in 2014. Meanwhile, 21% say they will cut back on hours and another 13.5% say they will seek a ‘non-clinical’ job in healthcare. Doctors are being dogged by ‘poor morale’ and ‘invasive regulations,’ according to the survey… ‘Many physicians are dissatisfied with the current state of the medical practice environment and they are opting out of traditional patient care roles,’ said Dr. Walker Ray, president of the Physicians Foundation.” Japsen, Bruce. (Forbes, 9.21.16)
- Reflections of a Medical Ex-Practitioner. “When it became increasingly difficult to work according to my principles, I closed my practice, first joining a ‘prepaid’ group for 15 years, and then leaving patient care altogether. As more physicians leave active practice, it must be appreciated that a focus on the economics of health care is not the only, and perhaps not even the most important, reason for their disillusionment. The glow of the personal relationship one might have with one’s patients is being extinguished.” Marsh, Ed. (The Wall Street Journal, 4.7.14)
- I’ve Had It With Medicine! Sixteen Options for Second Careers. “If you’re thinking of quitting clinical medicine, you’re not alone. A 2010 survey by The Physicians Foundation found that 40% of doctors planned to drop out of patient care in the next 1-3 years, either by retiring or seeking a nonclinical job. …’Look at what you’re earning per hour of work,’ he said. ‘You may be getting less than plumbers, electricians, and landscapers.’ (Medscape Business of Medicine, 7.10.14)
- When a Physician Leaves, We All Lose. “When I heard that Dr Seth Bilazarian, author of Practitioner’s Corner on theheart.org on Medscape, was quitting clinical practice, I was dismayed but not surprised. Seth has spoken clearly about the increasing burden of paperwork, the farce that is electronic health records, and the toxicity of removing joy from the practice of medicine. Among the drone of healthcare jargon, Seth’s candor and plainspeak have stood out. It is distressing when experienced clinicians leave patient care before the normal time. It’s bad for patients. It’s bad for healthcare systems. And, it’s bad for the profession… Patients often ask me to refer them to a new primary care doctor. They want someone who has the time and emotional strength to listen. They want a caregiver who knows both the science and them. Sadly, these doctors are nearly gone. They are in a meeting somewhere, working a shift in a hospital, retired, or ‘not taking new patients.’ I’m afraid healthcare policy experts are making a rookie mistake. They are treating symptoms but missing the root cause. As it is in education, if we want good medicine, we must value the human element of patient care. Somehow, we must find a way to care more for the caregivers.” (Mandrola on Medscape, 10.15.15)
Loss of Independent Practices
- ACA Hassles, Payment Cuts are Top Reasons Physicians Sell Practices. “Thirty-two percent of physicians who sold their practice within the past 3 years cited the complexities of the ACA as a primary motivator for the sale, according to a nationwide survey by Jackson Healthcare, a health care staffing firm.” (American College of Surgeons, ACS Surgery News, 2.20.14)
- Obamacare Deals Blow to One-Doctor Medicine. “‘The medical world is going IT, and this will be very hard for small physician practices,’ Cutler said recently via email. ‘Just as small retail stores had to find a niche they could fit in with bigger, IT-enabled competitors, so too will small M.D. practices. Undoubtedly, many will not survive.’… So far, nobody knows if the move to factory-style medicine will improve the quality or cost of care. Yet there’s no question that patients are losing something valuable. It’s OK to be sad about this.” (San Diego Union-Tribune, 4.26.14)
- Young Physicians OK With Obamacare While Older Doctors Bristle. “A reason for the generational differences could be that younger doctors aren’t as close to the bureaucracy of insurance and changes in reimbursement since more physicians are leaving private practice to become employed.” Japsen, Bruce. (Forbes, 9.21.14)
Federal Management Failures
- ACA’s Open Payments Website Suffers Delays, Glitches Ahead of Launch Date “At issue is a database known as the Open Payments website. It was created under the Affordable Care Act to shed light on the financial ties between doctors and pharmaceutical companies as well as device manufacturers…The government is hoping to take the site public on Sept. 30. But it’s already a year behind schedule, and if some industry heavy hitters have it their way, the schedule will slip by another six months. The American Medical Association as well as 112 other health organizations are pressing the government to delay the launch until March 31, 2015. They cite an overly complex registration process – made up of more than 20 individual steps that require a doctor to register over a period of several days in order to see their data – as one reason why the government should hold off.” (FOX News, 8.31.14)
- Alaska Doctors Overwhelmed By New Federal Rules. “EHR, ICD-10 and PQRS may sound like alphabet soup. But most doctors around the country know exactly what those acronyms stand for. They are programs championed by the federal government to improve quality and bring medicine into the electronic age. But in Alaska, where small medical practices and an aging physician workforce are common, the new requirements can be a heavy burden… ‘This flurry of things one has to comply with,’ Korshin says, ‘means that unless you work for a large organization like a hospital that can devote staff and time to dealing with these issues, there’s no economy of scale, I can’t share these expenses with anybody.’” (Kaiser Health News, 11.24.14)
- Doctors Say Obamacare’s EHR Mandate is Too Costly, Results in Worse Care. “According to the Department of Health and Human Services, Obamacare’s electronic health record mandate would ‘reduce paperwork and administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care.’ Now that the law has been implemented, it doesn’t appear that any of those goals have been met, at least not as far as a majority of American physicians are concerned… Medical Economics released the results of a survey of doctors on the functionality and cost of electronic health record (EHR) systems. Despite subsidies from the federal government, physicians reported that the EHR systems were not worth the cost, which includes licensing fees, training, hardware and increases in staffing. Doctors also reported that they have become less productive.” (Watchdog.org, 2.20.15)
- Also see EHR News and Analysis.
Impact on Physician Income
- Eight Ways the ACA Affects Doctors’ Incomes. “As the Affordable Care Act (ACA) moves toward its key implementation phase next year, this massive law is starting to affect physicians’ incomes in a variety of ways.” (Medscape.com, 8.15.13)
- “Health Plans to Docs: Curb Costs or We’ll Kick You Out.” “Doctors can join a large healthcare system that can negotiate favorable contracts with plans, or they can demonstrate the quality of their care to payers, he says. ‘If they’re primary care doctors, they can become part of patient-centered medical homes,’ he adds… ‘As a physician, I’m sympathetic to physicians who feel they’ve been unfairly excluded [from insurance networks],’ he says. ‘But they have a choice to make: They can lower their prices, or they can find a way to demonstrate higher quality. Or they can make the case that competition is not the right way to allocate healthcare resources.’” (Medscape Medical News, 5.9.14)
- Less Money, More Rules for US Physicians in 2015. Author describes Meaningful Use penalties and Medicaid pay cuts. “In a statement issued back in October, the AMA warned the CMS about the ‘regulatory tsunami’ facing US physicians that could cut Medicare payments by more than 13% by the end of the decade.” (Medscape Medical News, 1.2.15)
- New Estimate Of Obamacare’s Fiscal Impact On Private Doctor Practices. “Under Obamacare, doctors have been strained by costly new regulations, intricate payment ‘reforms’ that tie their Medicare reimbursement to complex federal reporting requirements, and mandates that they install and make ‘meaningful’ use of electronic health records. Add a new burden to the mix: The proportion of patients they see are rapidly shifting away from commercial health plans and toward Medicaid, which sometimes pays doctors pennies on the dollar that they were previously reimbursed under private insurance. The data comes from ACAview, a product of athenahealth that aims to measure the impact of Obamacare on medical practices. The project, jointly funded with the Robert Wood Johnson Foundation, is the first large-scale examination of data derived directly from outpatient medical practices belonging to more than 60,000 providers. It gives a unique insight into how the Affordable Care Act is impacting patients at the point of care.
- In states taking Obamacare’s Medicaid expansion, Medicaid visits as a proportion of all visits to doctors increased from 15.6% in 2013 to 17.7% in 2014, and continues to climb, to 21.5% in 2015.
- Meanwhile, in states that didn’t expand their Medicaid programs, the proportion of visits covered by Medicaid remained largely flat at 9.4% for 2013, 9.2% for 2014, and 8.9% for 2015.
- The proportion of commercially insured patients, either through Obamacare’s exchanges or through workplace coverage, actually fell in states that expanded their Medicaid programs.
- In those states, commercially insured patients comprised 65.2% of all patients in 2013, 64.4% in 2014, and then fell to 62.8% in 2015.
- In states that didn’t expand their Medicaid programs, the percentage of commercially insured patients rose slightly, from 66.1% in 2013 and 2014, to 68.1% in 2015.
- In states that expanded their Medicaid programs, the proportion of Medicaid patients visiting doctor offices as a percentage of physicians’ total patient volume is rising sharply, by almost 40% since 2013. Accepting that Medicaid pays much less than private coverage, this sharp change in payer mix will wreak havoc on doctors’ bottom lines.” Gottlieb, Scott. (Forbes, 5.29.15)
Research and Analysis
- How Will Physicians Be Affected by Health Care Reform? (Urban Institute, July 2010). “According to the authors, physicians will likely benefit financially as coverage expands—at worst they will be unaffected financially. Although physicians understandably have been focused on the Sustainable Growth Rate policy and its potential for large Medicare fee cuts, many may benefit from the key provisions of health care reform. Expansions in insurance coverage and increases in fees for primary care services will have direct benefits on practice revenues for large numbers of physicians.”
- Health Reform, Primary Care, and Graduate Medical Education (John Iglehart, New England Journal of Medicine, 8.5.10). “As the vast expansion of coverage that is called for in the reform law approaches in 2014, Congress will have to decide whether to expand Medicare’s GME support and how to define with greater clarity the roles that federal and state governments will play in shaping the workforce… At the time of the law’s enactment, Dr. Darrell Kirch, the CEO of the Association of American Medical Colleges, said in a statement, ‘The nation’s medical schools and teaching hospitals now stand ready to work with the administration and Congress to advance significant changes to our health care delivery system.’”
- When Will The Government Start Forcing Doctors To See Obamacare Patients? “Patient access to doctors is approaching a perfect storm of decreased physician supply, more demand for medical care—especially after Obamacare kicks in—and doctors increasingly refusing to see low-paying Medicare or Medicaid patients. If the ‘promise’ of Obamacare’s access to health care is to be kept, government will eventually have to force doctors to accept Obamacare-covered patients. Because such a step would represent such a radical departure from physician autonomy, you might call it the ‘medical nuclear option.’ [See a related piece on Medicare and Medicaid reimbursement cuts here.]” Matthews, Merrill. (Forbes, 11.25.13)
- How Healthcare Reform Handcuffs Doctors, Creates Issues. [Video]: “What happened with the ACA was that there was no protection. Doctors should be protected if they follow the protocols. The national protocols should be protecting them from lawsuits. It should be a safe harbor, but what happens is that in one room, we are self-insured for medical malpractice, and we tell our doctors not to be afraid to order a test; and in the next room, we are standardizing care and trying to squeeze cost out from under the world of population health.” (Medscape Business of Medicine, 11.12.14)
- Five Biggest Challenges Specialty Physicians Face From Health Reform. “Health reform hopes to improve health care by broadening the population that receives health care coverage, and raising the quality of health care, among other things. However lofty the goals, the implementation of health reform will undoubtedly create a number of new challenges for specialty practice.” Addresses: Pressure from physician shortages; Physician reimbursement pressures; New payment methods replacing fee-for-service; Non-insurance/concierge practice models: Electronic health record incentives and ICD-10 conversion. (Bank of America Merrill Lynch, December, 2014)
- Healthcare For Me, But Possibly Not for Thee. [Opinion] Internist Jason D. Fodeman writes about the ACA’s Patient-Centered Outcomes Research Institute (PCORI), the Value-Based Payment Modifier (VBPM), and the Independent Advisory Board (IPAB). “At first glance, the three examples I’ve named mainly apply only to Medicare. Yet trends in Medicare inevitably influence—and even dictate—trends in the private insurance market, as studies in recent years have demonstrated. Changes in Medicare reimbursement rates typically lead to changes in private insurance reimbursement rates. Similarly, insurers typically mimic changes in Medicare coverage. Given these trends, the Affordable Care Act is likely to lead to longer waits, restricted access, and worse health care for a significant percentage of patients.” (The Hill, 1.8.15)
Physician Analysis: ACA Impact on Costs
- A Physician’s View of the ACA. “The unfortunate reality is that the budgets drawn up in kitchens across this country do not have the luxury of ‘Washington math.’ Inside ‘the Beltway,’ a slower pace of increase has been counted as a decrease, as a savings, by a consecutive number of administrations. Everywhere else, an increase is an increase, and Americans are feeling the squeeze. When the President asks people to cut their cable bill in order to buy health insurance on the exchange, he doesn’t seem to realize the numbers of patients that I see who are already dropping cable in order to heat their homes or put food on the table.” Hood, Greg, M.D. (Medscape Medical News, 3.14.14)
- Large Healthcare Cost Increases Are Built Into Obamacare Implementation. “The ACA is projected to insure millions of additional persons, and insurance coverage has historically correlated very strongly with healthcare utilization… We propose four steps that will reduce healthcare costs without causing an adverse impact on the access to care promised by the ACA. Step 1: Eliminate the site of service differential. Step 2: Eliminate all government regulations that do not have a positive benefit to cost ratio. Step 3: Ask physicians to use only technologies with proven efficacy for patients. Step 4: Initiate programs that help patients make healthy lifestyle choices by supporting individual responsibility.” (The Physicians Foundation, Forbes.com, 5.28.14)
- Busy Doctors, Wasteful Spending. “Of all the ways to limit health care costs, perhaps none is as popular as cutting payments to doctors. In recent years payment cuts have resulted in a sharp downturn in revenue for many hospitals and private practices. What this has meant for most physicians is that in order to maintain their income, they’ve had to see more patients… Racing through patient encounters, we practice with an ever-present fear that we will miss something, hurt someone and open ourselves up to legal (not to mention moral) liability. To cope with the anxiety, we start to call in experts for problems that perhaps we could handle ourselves if we had more time to think through a case. The specialists, in turn, order more tests, scans and the like… Even though physicians’ salaries account for a relatively small fraction of health care costs, physicians’ decisions may affect upward of 80 percent of total health spending.” Jauhar, Sandeep, M.D. (New York Times, 7.21.14)
- Doctors Pan Obamacare in Survey. “A narrow majority of physicians say Obamacare has a negative impact on medical practice, including on the quality and cost of health care, according to a report from the Journal of the American Medical Association. The report found that 52 percent of physicians look on Obamacare as unfavorable to the general medical situation, while 48 percent say it is favorable. According to the report, 36 percent of physicians said the Affordable Care Act had a negative impact on the medical practice overall. Only 23 percent said it had a positive impact. Thirty-one percent physicians said the healthcare law had no impact, and 9 percent said they were not sure if it had an impact. Twenty-five percent of doctors said that Obamacare had a negative impact on the quality of patient care, while only 18 percent said it had a positive impact. Thirty-five percent said the healthcare law had a negative impact on the ability to meet patient demand, and only 10 percent said it had a positive impact in this regard. Finally, 44 percent of physicians said Obamacare had a negative impact on the cost of patient health care and only 21 percent said it had a positive impact.” (Free Beacon, 12.1.15)
- Patients Seeking Cheaper Care Are Soliciting Bids From Doctors Online. “Francisco Velazco couldn’t wait any longer. For several years, the 35-year-old Seattle handyman had searched for an orthopedic surgeon who would reconstruct the torn ligament in his knee for a price he could afford. Out of work because of the pain and unable to scrape together $15,000 – the cheapest option he could find in Seattle – Velazco turned to an unconventional and controversial option: an online medical auction site called Medibid, which largely operates outside the confines of traditional health insurance. The four-year-old online service links patients seeking non-emergency care with doctors and facilities that offer it, much the way Priceline unites travelers and hotels.” (Kaiser Health News, 8.5.14)
- Traditional Primary Care, Meet Next Year’s Model. “I recently took my kids to Walgreens, but it wasn’t to pick up a prescription or to stock up on candy. It was for primary care. And if this experience represents the new standard for primary care delivery, traditional physician practices should be watching retailers like Walgreens very closely.” (The Advisory Board Company, 11.20.14)
- Shopping Tools Help Patients Find Cash Prices for Medical Procedures. “MediBid, which has been in business since 2010, has returned up to 17 bids from doctors nationwide for knee replacement surgeries and often six or seven for common procedures, such as colonoscopies, says founder and Chief Executive Ralph Weber. Dr. Peter LePort, a general surgeon practicing in Fountain Valley, participates with MediBid. He says he’s seen a rise in the number of patients with high-deductible health plans looking for cheaper alternatives. Paying cash instead of using insurance often helps them get lower prices. ‘The demand is out there. People in general know how to shop, and they are just learning how to shop in the medical marketplace,’ LePort says. With rising out-of-pocket expenses, patients are increasingly demanding information about price and quality that historically has been unavailable.” (Los Angeles Times, 4.19.15)
- Retail Clinics May Increase Medical Spending, Rather Than Trimming Costs. “Researchers estimated that 42 percent of the visits to retail clinics for low-acuity ailments represented substitution for a visit to a physician office or emergency department, with 58 percent representing new use of medical services. Each use of retail clinics for new medical services increased per person spending by an average of $35 per year. That was partly offset by $21 in savings among those people whose visit to a retail clinic substituted for higher-priced medical care. So the overall spending increase prompted by retail clinics was $14 per enrollee annually, according to the study. While the overall increase was modest, it did represent a 21 percent increase in spending for low-acuity conditions. “‘While retail clinics do allow some users to lower their medical spending, the new use of medical services outweighed the savings from the substitution we observed among the large group of people we studied,’ said Scott Ashwood, the study’s lead author and an associate policy researcher at RAND, a nonprofit research organization.” (RAND Corporation, 3.7.16)